Health-Care

Is the White House Trying to Sabotage Paul Ryan?

While everybody in Washington expected the Congressional Budget Office to predict some decline in health insurance coverage under the House Republican plan to repeal and replace Obamacare, the federal scorekeeper’s final report still managed to provoke bipartisan shock. The headline number was front-page news on newspapers across the country Tuesday morning: by 2018, an estimated 14 million people would lose coverage, driven by a surge of young, healthy people dropping their insurance. By 2026, that number would swell to 24 million as the bill’s deep cuts to Medicaid kick in, making health care unaffordable for large numbers of older people, particularly in rural areas. Premiums would rise for several years before falling slightly, and then only relative to the Obamacare baseline.

The prevailing winds on Capitol Hill seemed to shift overnight. “Can’t sugarcoat it. Doesn’t look good,” Republican Senator Bill Cassidytold Politico, echoing several of his fellow senators. “The C.B.O. score was, shall we say, an eye-popper.” Senate Majority Whip John Cornyn suggested that the upper chamber would go a different way from the House, though he said it would be “premature” to say that Paul Ryan’s plan couldn’t pass.

Ryan, for his part, appeared pleased with the C.B.O. report. While Health and Human Services Secretary Tom Pricesaid the White House disagrees “strenuously” with its analysis, Ryan released a statement highlighting the C.B.O.’s conclusion that premiums would eventually grow more slowly under his plan. “Our plan is not about forcing people to buy expensive, one-size-fits-all coverage,” he wrote. “It is about giving people more choices and better access to a plan they want and can afford.

Plenty of other Republican lawmakers, however, aren’t sold. The arch-conservative House Freedom Caucus still believes Ryan’s plan is overly generous, arguing that the Obamacare repeal should be starker and swifter. Moderates in the Senate appear poised to vote against anything that cuts too deeply into Medicaid, which has proven immensely popular in red states that accepted the program’s expansion.

Meanwhile, another sort of backlash has been brewing among the Bannonites on the party’s right-nationalist flank. “Obamacare 2.0 is all but guaranteed to impose crushing costs on voters, hurt Trump’s base, and and hand power back to Democrats” blared one headline last week on Breitbart, the alt-right organ formerly run by Steve Bannon. On Monday, in the wake of the C.B.O. report, the the front page was more blunt: “Under Ryan plan, 14 million to lose insurance by 2018... ... 24 million by 2016.” Underneath was a photo of Ryan, holding up a copy of the American Health Care Act.

Speculation that Trump’s chief strategist might have nodded at Breitbart’s effort to drive a wedge between the president and House Speaker deepened on Monday night, when the conservative outlet published an audio recording from October of Ryan vowing that he was “not going to defend Donald Trump—not now, not in the future.” According to Axios’ Mike Allen, the embarrassing clip had been jealously guarded by Ryan’s opponents waiting for a “time of maximum vulnerability” to drop it. That same night, the White House’s own analysis of Ryan’s health-care plan leaked to Politico, revealing that the of Management and Budget predicted an even more dire outcome than the C.B.O. (The White House countered that the document was only a preliminary estimate of the C.B.O.’s ultimate findings and was not a formal report.)

It’s impossible to tell whether Trump or Bannon are setting Ryan up to fail or merely making missteps of their own. Bannon, who once vowed to destroy Paul Ryan’s career, has helped take the lead negotiating with the House Freedom Caucus, offering concessions to the far-right group—like speeding up the end of the Medicaid expansion—that could serve as a poison pill in the Senate. If so, it’s not clear where Trump’s own head is at. On Monday, he warned Republicans that should Ryan’s bill not pass, the only alternative would be to let Obamacare stand and collapse on its own. “It’s a disaster, and people understand that. It’s failed, and it’s imploding. And if we let it go for another year, it’ll totally implode. In fact, I’ve told the Republicans, ‘Why don’t you just let it go for another year?’ That way everybody will really understand how bad it is.”

It’s possible that option would give Trump more room to maneuver, and to deliver for his base. “Trump throws Ryan under the bus. Negotiates a deal and they pass it,” one Republican lobbyist speculated to Mike Allen, attempting some game theory. Another offered a contrasting take: “More likely Trump gets Ryan to make changes but has to campaign to help get the votes in the House.” Either way, it seems the deepening G.O.P. civil war is giving the White House more negotiating power, not less. If the Breitbart wing of the party is able to bring down Ryan in the process, eliminating a major ideological obstacle to Bannon’s nationalist-populist vision, all the better.